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Systolic dysfunction and complete heart block as complications of fulminant myocarditis in a recovered COVID-19 patient.

ABSTRACT: We describe the first case report of fulminant myocarditis and complete heart block which was initially presented by severe systolic dysfunction and tachyarrhythmia, in a patient who recently recovered from covid-19. Continuous close follow-up should be considered for patients infected with COVID-19 after discharge, especially for those with any metabolic and pharmacologic risk factors for the conductive block to recognize these rare complications and reverse CHB early by administering a high dose of corticosteroid or other anti-inflammatory medications. <Learning objective: To illustrate the presentation of COVID-19 fulminant myocarditis by severe systolic dysfunction, tachyarrhythmia, and different degrees of atrioventricular block. To introduce the proper management of fulminant myocarditis in a patient who recently recovered from covid-19.>.

SUBMITTER: Nikoo MH

PROVIDER: S-EPMC8057742 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundComplete heart block (CHB) as a first presentation of acute viral myocarditis is a rare occurrence associated with increased morbidity and mortality. In such cases, an endomyocardial biopsy is recommended to make a clear histological diagnosis aiding to differentiate from other possible conditions such as sarcoiditic myocarditis, giant cell myocarditis, and eosinophilic myocarditis. Insertion of a permanent pacemaker may be considered on a case-to-case basis.Case presentationA previously healthy 21-year-old female presented to the emergency department after having suffered two episodes of syncope on a background of a few days' history of myalgias, chills, and rigors. Electrocardiogram showed high-grade Mobitz II block with intermittent periods of CHB. A bedside echocardiogram upon admission demonstrated normal biventricular systolic function. Given the patient's unstable haemodynamic status and lack of obvious reversible causes for the CHB, a permanent dual-chamber pacemaker was inserted urgently. Initial blood investigations indicated an ongoing inflammatory process highlighting the possibility of myocarditis as a cause of the CHB. Therefore, a troponin level was taken and was noted to be elevated confirming the suspicion of myocarditis. The left ventricular ejection fraction (LVEF) decreased over the following days to approximately 20%, clinically resulting in pulmonary oedema and acute shortness of breath. The patient required aggressive intravenous diuresis and anti-heart failure medication. An endomyocardial biopsy (EMB) confirmed the diagnosis of lymphocytic myocarditis. The patient's condition improved secondary to an improvement in LVEF and resolution of the heart block. A cardiac magnetic resonance (CMR) imaging performed 6 weeks from admission reported an improved LVEF of 51% with no late gadolinium enhancement (LGE). Based on the reassuring CMR findings and the resolution of CHB on follow-up pacemaker checks, it was deemed safe to explant the pacemaker.ConclusionsAcute myocarditis may be complicated with high-degree AV block and cardiogenic shock necessitating close observation in a critical care unit. A permanent pacemaker may provide atrio-ventricular synchrony which helps stabilise the patient's condition and protect from a prolonged period of heart block. Early myocardial fibrosis on EMB and degree of LGE on CMR are indicators of persistent atrioventricular block. Guideline-directed treatment of heart failure is essential.

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Systolic dysfunction and complete heart block as complications of fulminant myocarditis in a recovered COVID-19 patient.

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